STEMI | Figure 1

STEMI

70s-year-old male mowing his lawn developed chest pain that briefly subsided, then returned. Patient presented with Levine Sign, diaphoretic, rocking back and forth. History of MI with stent placement in LAD 10 years prior, controlled HTN. On ASA and Plavix at home.

The patient was taken emergency to Level 2 STEMI center 40 minutes away.

Patient was given 324 ASA dissolved in 10 ml of saline (due to no teeth), 2 x 0.4 NTG SL and 2 x 100mcg Fentanyl IV.

During transport patient developed bradycardia without hypotension and bigeminy. Cardiac pads were preemptively placed.

Upon arrival patient was taken immediately to Cath Lab. Lesions were stented in the RCA and Right Marginal.

Diagnosis

Inferior MI. Lesion of RCA.

Case Details

Patient initially presented to EMS with sudden acute chest pressure. Given ASA, NTG, and Fentanyl with no relief. Patient taken to STEMI point of entry, was speaking with the doctor and then went into witnessed V-fib arrest. Immediate defib was performed but was refractory. Resuscitated after 8 minutes and was able to follow commands. Patient intubated due to desaturation. Patient went into V-fib 3 more times; immediate defibrillation returned him to sinus rhythm. Taken to cath lab, finding 100% proximal LAD occlusion, patient stented. Extubated shortly after and doing well despite subsequent troponin results coming back negative.

Summary of PCI Details

• Acute total occlusion of proximal RCA
• 100% occlusion, class C, TIMI 0 (Pre-intervention)
• 0% residual stenosis and TIMI 3 flow (Post-intervention)
• IVUS confirmed the stent was fully expanded and well apposed
• No dissection or distal embolization or perforation noted
• Antiplatelet therapy initiated with ASA and Ticagrelor

Additional Cases

1. 60’s F, chest ache x20 minutes radiating down left arm:

   • Patient became diaphoretic, called 911. History: COPD, hypertension.
   • Medications: Losartan, Albuterol, Spiriva, HCTZ.
   • CPT results confirmed 100% occlusion of RCA which required PCI with overlapping stents.
   • Conclusion: Successful PCI with IVUS guided intervention.

2. Patient with sudden acute chest pressure:

   • Presented with chest pressure, history of hypertension, underwent PCI for intentional LAD 100% occlusion. Successful treatment.

3. 28-year-old woman with intense pruritus:

   • Symptoms included multiple vesicles over the lower back. Exam revealed significant skin presentation.

4. 4-month-old infant with skin lesions:

   • Noted pustules with inflammatory signs, systemically well.